Nasal Valve Stenosis Research Articles

Nasal peak inspiratory flow (NPIF) as a diagnostic tool for differentiating decongestable from structural nasal obstruction

Identifying the cause of nasal obstruction is critical before surgical intervention. Structural nasal obstruction, due to nasal valve stenosis, is unlikely to benefit from simple septoplasty and turbinate reduction. This study assesses changes in nasal peak inspiratory flow (NPIF) as a tool for discriminating decongestable versus structural obstruction. Cross-sectional study of patients undergoing nasal airflow assessment was performed. Rhinomanometry, nasal obstruction visual analogue scores (VAS) and NPIF were performed pre- and post-decongestion. Population groups were defined with decongestable or structural obstruction by relative post-decongestion changes in airways resistance and symptoms. Fifty two patients were assessed, 24 with decongestable, 28 with structural obstruction. Pre- and post-decongestion NPIF were similar between groups. Absolute and percentage NPIF change were larger with decongestable versus structural obstruction. Sensitivity and specificity for predicting decongestable obstruction were 75.0% and 60.7% for NPIF increase >20 L/min; 75.0% and 64.3% for NPIF increase >20%. The respective positive predictive values were 62.1% and 64.3%. NPIF increase after decongestion is larger with decongestable than structural nasal obstruction. NPIF alone cannot discriminate the two conditions and does not replace more formal assessment.

Techniken der Nasenrückenkorrektur

Correction of the nasal dorsum ranks among the most common surgical procedures in rhinoplasty. Due to the involvement of nasal support structures such as septolateral cartilage and the K and scroll areas, these procedures have both aesthetic and functional impacts. In addition to spreader grafts and spreader flaps, the most important surgical methods currently include the split hump reduction technique, cartilage-fascia transplants and cartilage grafts from rib and ear. In addition to serving to correct deformities, the techniques described here help prevent complications such as inverted V, hourglass and saddle nose deformities, as well as nasal valve stenosis. The basic operative principle calls for reinforcement and reconstruction of the anatomical support structures, while avoiding overresection and mucosal lacerations.

Nasenatmungsbehinderung nach Septumplastik: Deviation der Lamina perpendicularis bei Schiefnase

Functional septorhinoplasty (SRP) is a surgical procedure for improvement of symptomatic deformity of the inner and outer nose. Due to inadequate preoperative analysis and consequently insufficient surgical indication, septoplasty (SPL) alone may be performed. A frequent cause for revision septorhinoplasty (rSRP) in our institution was found to be due to a deviated bony pyramid in compound with a contralateral high deviation of the perpendicular plate, ipsilateral reluxation of the cartilaginous septum and a resulting nasal valve stenosis. The medical records of all patients undergoing revision septorhinoplasty in our institution from 2005-2011 were evaluated retrospectively.398 patients underwent rSRP, in 57 patients (14%) a deviated bony nose after septoplasty was diagnosed. In all cases a deviated bony nose and contralateral deviation of the perpendicular plate was found and corrected by rSRP. The nasal breathing was improved in all cases. This was also shown in an increase of endonasal volume and nasal air flow in acoustic rhinometry and active anterior rhinomanometry. A deviated nasal pyramid and perpendicular plate was found to be a common cause for persistent nasal obstruction after septoplasty. A careful preoperative analysis of the nose, the pathology of the bony and cartilaginous septum and the nasal valves is mandatory in order to recognize anatomical details and set up the right indication for rhinosurgical interventions.

Nasal valve dysfunction: diagnosis and treatment

This article reviews the etiology and treatment options for nasal valve stenosis (NVS), a common cause of nasal obstruction. It is based on meta-analyses, published expert panel opinions, extensive literature review, and previously published results of our own clinical experience. Diagnosis and management of NVS continue to evolve. Although most studies that describe the surgical techniques of nasal valve repair report an improvement in patient complaints, there is a paucity of controlled trials that point to the most effective method. Lack of high-grade evidence may be due to ambiguities in objectifying patient complaints, standardizing treatment, and the lack of adequate controls. Recent literature addresses these ambiguities and provides suggestions on future directives in research. There is also a trend towards minimally invasive treatments that are effective in treatment of appropriate patients. The diagnosis of NVS is primarily based on the subjective feeling of nasal obstruction associated with specific findings on the physical examination. Patient complaints are best objectified with validated questionnaires. Treatment of this condition is typically surgical and, as is evident by the plethora of described surgical procedures, there is often no consensus as to the best choice even in patients with identical findings on physical examination.

Minimally Invasive Nasal Valve Repair

To determine the efficacy of a new surgical procedure to correct symptoms of nasal obstruction secondary to internal nasal valve narrowing. Consecutive case series. Tertiary care multispecialty clinic. Patients with symptoms of nasal obstruction for at least 1 year, a closed but otherwise anatomically normal nasal valve, and resolution of symptoms with lateralization of the upper lateral cartilage. Surgical correction of nasal valve stenosis by fibrocartilaginous resection and imbrication at the caudal upper lateral cartilage. Validated Nasal Obstruction Symptom Evaluation (NOSE) scale score. Highly significant improvement was seen in nasal obstruction symptoms after the procedure. A significant correlation between the reported improvement and the preoperative NOSE scale scores was demonstrated (P < .01). There was poor correlation of symptomatic improvement with acoustic rhinometry measurements. The described surgical repair is highly successful in relieving symptoms of nasal obstruction due to nasal valve stenosis in this selected group of patients. Patients with more severe symptoms of obstruction derive the greatest benefit.

Role of nasal muscles in nasal valve collapse

Objective This study was performed to determine the role of nasal muscle function in patients with dynamic or static nasal valve collapse by comparing the electromyographic activities of nasal muscles in healthy individuals. Study Design Cross-sectional clinical study. Setting Tertiary referral center. Subjects and Methods Twenty adult patients with dynamic nasal valve collapse, 18 patients with unilateral static nasal valve stenosis (septum deviation), and 20 healthy adults were included in the study. The activity of their nasal muscles was measured by surface electromyography (EMG), and the results were compared for the patient and control groups. Results No abnormal finding was found in any of the nasal muscles of the control group. In the majority of patients with dynamic nasal valve pathology, statistically significant functional disorders were detected in the m dilator naris anterior and m nasalis transversalis muscles compared with the controls. During inspiration and expiration in patients with static nasal valve pathology, some revealed muscular abnormities during inspiration. Normal muscle activation was observed in all of the patients during expiration. Conclusion Determination of agents involved in pathologies of the nasal valve region is necessary for planning appropriate treatment. The role of nasal muscles in dynamic nasal valve pathologies, which has not been previously recognized, should be considered. A more effective and adequate solution for the nasal sidewalls than static pathologies should be considered in these patients by taking into account the muscular activity disorders detected by EMG at the stage of surgical treatment.

Correction of Internal Nasal Valve Stenosis

Nasal obstruction due to internal nasal valve (INV) collapse is relatively common. This article evaluates 2 different methods repairing the INV.Our subject population is a single-surgeon group of 82 patients who underwent a septorhinoplasty for nasal airway obstruction. Patients received either a spreader graft or butterfly graft. There are 30 patients who received spreader grafts and 52 patients who received a butterfly graft. All patients had a minimum of 3 months follow-up. All patients were evaluated with standardized questionnaire. Participants were asked to evaluate improvement in their nasal airway on an analog scale of 1 to 5. Participants were also asked to comment on changes in pre and postoperative snoring and sleep habits. Lastly, participants were queried regarding the ear cartilage harvest and if this bothered them.Patients undergoing both procedures demonstrated an overall improvement in their nasal breathing. Significant differences in improvement were observed for patients in the categories of postoperative snoring, sleep, and continuous positive airway pressure use. Patients were not bothered by the ear cartilage harvest.In select patients, the butterfly graft is a useful solution for INV collapse correction.

In-Office Surgical Repair of Nasal Valve Stenosis

Nasal valve (NV) stenosis is a well-known cause of nasal obstruction (NO) and congestion but it is often overlooked because the typical surgical therapies are complex and often associated with cosmetic changes. A simplified surgical procedure is needed to address straightforward stenosis of the NV in patients with no need of cosmetic improvement or cartilage grafting. The purpose of this article is to describe a simplified surgical procedure to relieve symptoms of NO without extensive surgical dissection, sedation, cartilage grafting, or cosmetic change. This article describes a retrospective consecutive case series of patients that underwent a surgical procedure to correct NV stenosis in the office setting. The procedure is described in detail along with patient outcome assessment using a visual analog scale of patient satisfaction and a questionnaire regarding perceived postoperative cosmetic changes. Of 190 patients that underwent the procedure, 36 were done in the office setting and 28 completed the questionnaires. Six patients (21%) reported an improvement score of 10, a score of maximal improvement in breathing. The mean breathing score was 4.4, indicating an overall improvement in breathing ability after correction. No patient reported a major cosmetic change and three patients reported a subtle change. The remainder (89%) reported no perceived change in cosmesis. In-office surgical correction of the NV specifically targeting the mucosa, fibrous tissue, and caudal upper lateral cartilage was feasible, safe, and reliable in relieving complaints of NO due to uncomplicated NV stenosis.

Intranasal Z-plasty for Internal Nasal Valve Collapse

To describe the technique of intranasal Z-plasty and early results for this minimally invasive method to repair internal nasal valve collapse. Intranasal Z-plasty has been well described for nasal valve stenosis and cleft nasal deformities but poorly described for idiopathic nasal valve collapse, the most common indication for nasal valve surgery. A retrospective medical record review was performed for 12 patients undergoing intranasal Z-plasty for nasal valve collapse. Medical records were evaluated for age, sex, indication for surgery, prior surgical procedures, complications, results, and length of follow-up. A visual analog scale was used to rate nasal obstruction preoperatively and postoperatively. A total of 8 men and 4 women underwent surgery, and the procedure was bilateral in 10 of the 12 patients, for a total of 22 nasal valves. Eleven patients noted subjective improvement in airflow on both sides, with the remaining patient noting improvement on one side and no change in the opposite side. Mean follow-up was 16.8 months (range, 5-32 months). The mean preoperative nasal obstruction score was 7.2, and the mean postoperative nasal obstruction score was 3.3 (on a scale of 0 to 10, with 10 being total obstruction). No complications were reported, and no patients complained about postoperative nasal appearance. Intranasal Z-plasty appears to be a safe, effective, and relatively noninvasive technique to repair internal nasal valve collapse.

Biofeedback training of nasal muscles using internal and external surface electromyography of the nose

Background The purpose of this paper is to describe the outcome of biofeedback training of nasal muscles in cases of nasal valve stenosis and collapse. The present study was performed to investigate the best way of using surface electromyography (sEMG) in biofeedback training of muscles involved in nasal valve function. In the present study, we present the way of biofeedback training of these muscles introducing the intranasal placement of sEMG electrodes and a home exercise program. Methods A nonrandomized pilot study of patients presenting with symptoms of obstructed nasal breathing was conducted. All selected patients (n = 15) demonstrated nasal valve stenosis with a positive Cottle maneuver and clinically evident nasal valve collapse. Follow-up ranged from 9 to 12 months. Treatment included surface and intranasal EMG biofeedback-assisted specific strategies for nasal muscle education and a home exercise program of specific nasal movements. Results All patients exhibited variable subjective improvement. In 86.66% (n = 13), the improvement was proved objectively and there was no need for operation. In 13.33% (n = 2), an endonasal operation was recommended. Conclusion Relieve of obstructed nasal breathing after nasal valve stenosis and/or collapse can be achieved with biofeedback training of nasal muscles and a home exercise program as described. It helps a significant cohort of patients with symptoms of obstructed nasal breathing to avoid surgical intervention.

Treatment of nasal valve collapse with transcutaneous and intranasal electric stimulation

We conducted a prospective, randomized, double-blind pilot study of patients presenting with symptoms of obstructed nasal breathing to determine whether electrotherapy could provide nonsurgical symptom relief. Forty patients were divided into an electrotherapy group (n = 20) and a placebo group (n = 20). All selected patients demonstrated nasal valve stenosis with a positive Cottle maneuver and clinically evident nasal valve collapse. Treatment consisted of high-frequency transcutaneous and intranasal electric stimulation of nasal muscles for 15 minutes, 3 times a week for 10 weeks. Treated patients were followed for 10 to 12 months. Twelve patients in the electrotherapy group (60%) exhibited subjective improvement; in 8 cases (40%), the improvement was proved objectively. In the placebo group, 7 patients (35%) indicated subjective improvement; and in one case (50%), the improvement was proved objectively. Follow-up visits showed a rapid decline of positive results when treatment was discontinued. Therefore, we concluded that sure relief of nasal valve stenosis and collapse cannot be achieved with treatment by electric stimulation alone, and this method appears to have limited application. However, further studies are needed to determine whether electrotherapy used in combination with other treatments (e.g., biofeedback training or nasal springs) may provide more lasting relief for patients who want to avoid endonasal surgical intervention.

Bending of the Upper Lateral Cartilages for Nasal Valve Collapse

As a consequence of removal of the nasal hump, the upper lateral cartilages are separated from the septal cartilage in reductive rhinoplasty. A decrease in the nasal airway cross-sectional area and collapse of the internal nasal valve (INV) are inevitable unless additional surgical measures are taken. To determine the efficacy of the horizontal mattress bending suture in treating patients with nasal valve collapse. Each upper lateral cartilage was separately bent to a certain degree with a horizontal mattress suture following nasal dorsum reduction in the external septorhinoplasty as a preventive or corrective measure for the INV stenosis. The efficacy of this suture was assessed in 28 patients who presented with tension nose by comparing the INV angles preoperatively and 12 months postoperatively, as determined photographically by means of a rigid nasal endoscope. The mean +/- SD preoperative INV angle was calculated as 9.1 degrees +/- 4.2 degrees (range, 0 degrees -18.3 degrees ). The mean postoperative INV angle was increased to 25.3 degrees +/- 3.8 degrees (range, 18.4 degrees -34.5 degrees ) (P<.001). This method reconstitutes the normal anatomy of the INV, reestablishes stiffness or resistance of the nasal side walls so that they do not bend inwardly with inspiration, improves the airflow at this area, and avoids postoperative nasal valve stenosis in functional-cosmetic rhinoplasty cases that require considerable nasal hump reduction.

Correction of nasal valve stenosis with lateral suture suspension.

To evaluate the effectiveness of using suspension sutures to relieve obstructed nasal breathing caused by nasal valve stenosis. SUBJECTS, MATERIALS, AND METHODS: A nonrandomized pilot study of postrhinoplasty patients presenting with symptoms of obstructed nasal breathing was conducted in a private facial plastic surgery practice. All patients demonstrated nasal valve stenosis with a positive Cottle maneuver, clinically evident nasal valve collapse, and lack of response to efforts at reduction in turbinate size. Follow-up ranged from 7 to 12 months. Four men aged 31 to 58 years (mean age, 43 years) and 5 women aged 26 to 52 years (mean age, 39 years) were included in this study in a 1-year period. The nasal valve was suspended with 2 permanent sutures on each side, which were tunneled within the facial soft tissue to an infraorbital incision to lateralize the nasal valve complex and relieve nasal airway obstruction. Subjective self-assessment data for nasal airflow were collected. Preoperative and postoperative observation and photographic analysis provided objective data. All patients exhibited improvement. Relief of nasal valve stenosis can be achieved with suspension suture technique as described. It is effective and, in our experience, has been the most predictable means of achieving improvement in nasal obstruction secondary to nasal valve stenosis.

Surgery for Nasal Valve Stenosis

Nasal valve is now regarded slit-like opening between the caudal end of the upper lateral cartilage and the septum. Because of wider nasal valve angle than Caucasians, we have fewer chances to experience patients with stenotic nasal valve. However, with careful history taking and Cottle test, we can recognize patients with nasal obstruction due to nasal valve stenosis. They require surgical correction. Surgical intervention was directed toward reconstruction of normal anatomic relationships between upper-and lower lateral cartilage and between the former and septal cartilage. This is usually achieved by widening the nasal valve angle and preventing collapsibility. There are two methods of approach to the nasal valve ; transnostril approach and open rhinoplasty.1) Transnostril approach Retracting the ala by means of the blunt retractor, the lower border of the upper lateral cartilage is identified. Incision of the skin parallet to the lower end of the upper lateral cartilage at lmm distance (intercartilagenous incision). The incision is continued just beyond the angle of the valve. Dissection of the caudal end of the cartilage is performed by elevating the mucoperichondrium with sharp, slightly-curved scissors. A strip of cartilage is resected from the caudal end of the upper lateral cartilage.2) open rhinoplasty approach Notched transcolumellar incision at the level of the midcolumella. This incision is connected to bilateral columellar marginal incisions that is usually placed lmm behind the rim of the columella. By using scissors, the skin overlying the medial crura is dissected. The flap is carefully elevated up from the underlying medial crura. Then the flap is elevated off of the surface of the lower lateral cartilage. Decortication is accomplished with dissection of soft tissue form the region of the anterior septal angle. Caudal margin of the upper lateral cartilage is resected or fixed on the lower lateral cartilage.

Midfacial Degloving Approach to the Nose, Sinuses, and Skull Base

Thirty-seven patients with a variety of neoplastic, vascular, and traumatic lesions of the midfacial skeleton, orbits, and central compartment of the anterior and middle cranial fossae were managed surgically via the midfacial degloving approach. Excellent exposure was achieved in all patients. Complete removal of the lesion was achieved in all patients with neoplastic disease. Successful repair of the defect was achieved in all patients with traumatic injuries. The most common complication related to midfacial degloving was temporary infraorbital anesthesia or hypesthesia. Only one patient developed symptomatic nasal valve stenosis. Midfacial degloving has important advantages over other procedures, especially in cases where bilateral surgery is required or when the avoidance of midfacial incisions and scars is important. In the subgroup of inverted papilloma, midfacial degloving is currently our procedure of choice for en-block medial maxillectomy and ethmoidectomy.

Surgical approach to the nasal valve stenosis

Nasal valve, originally defined by Mink (1903), has changed its concept and is now regarded as slit-like opening between the caudal end of the upper lateral cartilage and the septum. Contrary to Caucasians whose smallest area of the nose lies at the nasal valve, the narrowest part of Japanese nose situates at the area between the anterior portion of the inferior turbinate and the septum. Thus, we have fewer chance to experience patients with stenotic nasal valve. Six patients complaining nasal obstruction resulted from nasal valve stenosis, mainly due to dislocated or collapsed upper lateral cartilage, underwent surgery during the last 2 years and a half. Cases of septal deformity, even it it produced valve stenosis, were excluded in this study. Surgical intervention was directed toward reconstruction of normal anatomic relationships, usually by widening the nasal valve angle and preventing collapsibility. Three underwent open rhinoplasty with gull-wing columellar skin incision, whereas 3 others were operated on via transnostril approach. History of midfacial trauma caused us to choose open rhinoplasty for restoring the function and structure. Immediate postoperative result was excellent in the aspect of appearance and subjective data regardless of surgical approach. Open rhinoplasty provided a splendid long-term result without remarkable complications. On the other hand, 2 cases operated via transnostril approach complained recurrence of stuffy nose.